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The painful wrist - TFCC

Wrist pain can be quite common in sports and even occur in an average household. Injury to the triangular fibrocartilage complex (TFCC) occurs with compressive load on the wrist such as in a racquet sport where repetitive bouts of force go through the wrist during the swing or simply from a mother picking up their newborn baby with a poorly positioned wrist. No matter who you are, the good news is the prognosis is generally favorable and you can quickly identify what the problem is and seek proper treatment.

What is TFCC?

The triangular fibrocartilage complex or TFCC injury is characterised by localised pain and swelling to the ulnar side (pinkie finger) of your wrist. This complex consists of multiple load-bearing structures including:

  • Triangular fibrocartilage

  • Ulnar meniscus homolog

  • Ulnar collateral ligament

  • Numerous carpal ligaments

  • Extensor carpi ulnaris tendon sheath

Mechanism of injury

TFCC’s main role is to stabilize the ulnar side of the wrist and the abovementioned structures reinforce the stability of the wrist complex and provide shock absorption. This injury occurs when TFCC is under load either from repetitive bouts or acute onset of trauma. It is most common in sports with high impact on the wrist, for instance golf, boxing, tennis, gymnastics, hockey, etc.

Types of TFCC injuries

Acute Tears – generally occur as a result of a significant incident or sudden trauma i.e. direct fall onto the wrist. Additionally, there is 39% to 84% of acute cases accompanied with fractured distal radius.

Degenerative Tears – typically due to repetitive overuse and age-related deterioration in the ligaments and cartilages.

What are the symptoms?

Symptoms of a TFCC injury can include:

  • Localised pain to ulnar side of the wrist especially with compression or load

  • Can experience clicking or point tenderness

  • Usually worsens with activity

  • Weakness in grip, instability or clicking

  • Restricted wrist movement

  • Pain bearing weight through an extended wrist

Physiotherapy management

Following an acute injury, there will be potential swelling and elevated pain. It's recommended that you visit your physiotherapist a few days after the injury. Our priority at this stage is to minimize and prevent further injury, reduce inflammation, and decrease pain.

  • Commence PEACE & LOVE acronym (Protect, Elevate, Avoid anti-inflammatory, Compress, Educate & Load, Optimism, Vascularisation, Exercise) *Refer to our previous blog for details*

  • Wrist brace/ splint or tape can be helpful to immobilise the wrist and reduce pain.

The next goal is to restore pain-free wrist range of motion and prevent secondary complications

  • Gentle manual therapy can be used

  • Soft tissue massage and swelling management

Depending on the severity of the injury, early strengthening of the wrist can commence as soon as 1 to 2 weeks after injury.

  • Isometric strengthening is usually welcomed without too much aggravation as we are not putting the joint through ranges of motion

Finally, we proceed onto a gradual return to work, sport and function

  • Gradual increase in loaded exercises i.e. can include weights, resistance bands, partial to full weight-bearing activities based on pain-level

Wrist strengthening using dumbbell: 3 sets of 10-12 begin with light weight i.e. 1kg and progressive onto 1.5kg or 2kg and weekly thereafter.

What happens if the pain persists or worsens?

TFCC injury can be complicated depending on whether the wrist is stable and the location of the tear. If the physio has assessed you and deemed your wrist unstable (likely due to sprain or tear on multiple structures) then further investigation might be warranted. The next step could involve getting a referral from your doctor for MRI and visiting a specialist to see if surgery is required. On the other hand, the vascular supply to the TFCC is only in the peripheral margins. Therefore, if the tear involves the avascular central disc of the TFCC, this will pose some serious issues and may need to be investigated further.

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